Abstract: The exchange of sexual activities for money, drugs, or
other compensation is considered a form of sexual exploitation when it
occurs among underage youth. Such practices have been associated with
sexual behaviours that increase the risk of sexually transmitted
infections. Much of the research on this issue has been conducted on
homeless or street-involved youth while adolescents in regular schools
have received less attention in this area. The present study examined
the prevalence of and factors associated with the exchange of sex for
drugs among substance-using students in rural western Canada. Our data
source was the 2009 East Kootenay Adolescent Drug Use Survey, a census
of students in grades 7-12, who had ever used alcohol, marijuana, or
other illicit drugs. In the sample of 2,360 youth, 2% of boys and 3% of
girls reported that they had ever exchanged sex for alcohol or drugs,
i.e., "exploited" youth, the majority of whom (83%-98%) were
living with family members. The most frequent patterns of past-year
substance use were "using alcohol only" for
"non-exploited" youth, and using alcohol, marijuana, and other
drugs for exploited youth. The exchange of sex was associated with the
use of drugs other than alcohol in the past year and with a higher level
of impulsivity. The odds of exchanging sex were lower among youth who
reported positive family relationships. The findings suggest a need for
in-school education about healthy relationships, sexual exploitation,
substance use, and impulse control.

Introduction

In conformity with Article 34 of the United Nations Convention of
the Rights of the Child (United Nations Office of the High Commissioner
for Human Rights [OHCHR], 1989) and the Optional Protocol on the Sale of
Children, Child Prostitution and Child Pornography (OHCHR, 2000),
children and adolescents must be protected from all forms of sexual
exploitation. The protection of children and adolescents from sexual
exploitation is both a human rights issue and a health issue. The
exchange of sexual activities for money, drugs, or other goods, a form
of sexual exploitation, has been associated with other risky sexual
behaviours, such as earlier sexual debut (Pedersen & Hegna, 2003;
Svedin & Priebe, 2007), a greater number of sexual partners
(Edwards, Iritani, & Hallfors, 2006; Pedersen & Hegna; Svedin
& Priebe), and involvement in casual sex (Lavoie, Thibodeau, Gagne,
& Hebert, 2010). These behaviours are known to increase the risk of
HIV and other sexually transmitted infections (STI); indeed, youth who
had engaged in trading sex were found to be more likely than those who
had not to report a history of HIV/STI diagnosis (Edwards et al.;
Greene, Ennett, & Ringwalt, 1999; Roy et al., 2000). While girls and
boys from a variety of circumstances may have experienced exploitation
related to exchanging sex, most of the research has focused on runaway,
homeless and street-involved youth. There have been fewer
population-based studies of youth in school settings. The present
investigation therefore focused on high school students in rural western
Canada to determine the factors that differentiated youth who had
exchanged sex for drugs from youth who had not.

Prevalence of sexual exchange

Reported rates of the exchange of sex vary depending on sample
characteristics, study sites, and sampling methods. In the United States
(U.S.), 10% of a nationally representative sample of youth living in
shelters and 28% of a multi-city sample of street-involved youth had
ever engaged in trading sex (Greene et al., 1999). A history of sexual
exchange was reported by 9% of homeless youth in 28 different U.S.
states (Walls & Bell, 2011), by 21% of homeless and street youth in
Minnesota (Halcon & Lifson, 2004), and 12% of incarcerated
adolescents in North Carolina (Castrucci & Martin, 2002). Canadian
researchers have also investigated the prevalence of trading sex among
street-involved youth and youth in custody. In Montreal, the rates among
street-involved youth (ages 13-25 years) were 21% for males and 38% for
females (Roy et al., 2000). In British Columbia (BC), 33-34% of
street-involved boys and 24-27% of street-involved girls (ages 12-19
years) indicated that they had ever exchanged sex for money or goods, as
did 18-21% of youth in custody (ages 13-19 years) (Saewyc, MacKay,
Anderson, & Drozda, 2008). Another BC study reported that among
street-involved, drug-using youth (median age = 22 years) in Vancouver,
11% had traded sex for money, drugs, or other resources in the past 6
months (Chettiar, Shannon, Wood, Zhang, & Kerr, 2010).

Although a majority of the studies on this topic have targeted
homeless and street youth, there are a few that have addressed the
prevalence of exchanging sex in general adolescent populations. In a
secondary analysis of the National Longitudinal Survey of Adolescent
Health (Add Health) using a nationally representative U.S. sample of 7th
to 12th graders, 3.5% reported having ever exchanged sex for drugs or
money (Edwards et al., 2006). Another analysis of the Add Health data
showed that among those who had not exchanged sex in Wave I, 2.3%
reported having ever sold sex in Wave III (ages 18 to 26) (Kaestle,
2012). A Norwegian study found that 1.4% of students in grades 8 to 10
had ever given sexual favors for payment (Pedersen & Hegna, 2003).
Likewise, 1.4% of 3rd-year high school students in Sweden reported
having ever sold sexual services (Svedin & Priebe, 2007). The single
Canadian study among students in grades 11 and 12 in Quebec City, found
that 4% reported having ever received something (e.g., money, drugs,
gifts) in exchange for sexual contact (Lavoie et al., 2010). These four
studies of adolescents in school also showed gender differences. In
three studies, boys were more likely than girls to report a history of
sexual exchange; 4.8% versus 2.3% (Edwards et al.), 2.1% versus 0.6%
(Pedersen & Hegna), and 1.8% versus 1.0% (Svedin & Priebe). In
contrast, the prevalence findings among students in Quebec City were 2%
for boys versus 6% for girls (Lavoie et al.).

Psychosocial factors have been shown to distinguish youth who have
exchanged sex for money or drugs and those who have not. Youth with
higher levels of depression (Edwards et al., 2006; Kaestle, 2012;
Pedersen & Hegna, 2003; Tyler, 2009) and loneliness (Pedersen &
Hegna), those with a history of suicide attempt (Greene et al., 1999;
Saewyc et al., 2008; Tyler), and those who experienced a greater number
of stressful life events (Lavoie et al., 2010) have been shown to have
greater risk of involvement in trading sex. Living situation and family
environments are well-established factors. Youth who had exchanged sex
were less likely to live with two parents (Kaestle) or either parent
(Svedin & Priebe, 2007). Homelessness and being a runaway were
associated with trading sex (Edwards et al.; Kaestle), although 20% of
street-involved youth in BC were living with their families when they
first exchanged sex for money or goods (Saewyc et al.). Youth with a
higher level of alcohol exposure at home (Pedersen & Hegna) and
those with a family history of substance abuse (Tyler) were more likely
to have ever traded sex. Friends' behaviours may also be associated
with greater risk of involvement in sexual exchange, e.g., some studies
have reported this association with having friends with conduct problems
(Pedersen & Hegna) or friends already involved in trading sex
(Tyler).

While dysfunctional social relationships and environments are risk
factors for exchanging sex, positive relationships with family and
school may reduce the likelihood of this behaviour. Few studies have
explored potential protective factors. In an analysis of longitudinal
data (Add Health), feeling cared about by a parent, feeling happy at
school, and feeling that teachers are fair were predictors of
non-participation in trading sex in a bivariate model (Kaestle, 2012). A
good relationship with mother had an inverse association with survival
sex (trading sex for money, shelter, or other rewards, and/ or
participating in pornography) among homeless youth, whereas no
association was found between their paternal relationship and survival
sex (Stein, Milburn, Zane, & Rotheram-Borus, 2009). A study of high
school students in Quebec City showed a significant bivariate, but not
multivariate, association between perceived social support and
involvement in sexual exchange (Lavoie et al., 2010).

The present study

The literature reviewed above indicates that the self-reported
prevalence of exchanging sex for money, drugs, or other goods among
adolescents in regular schools ranged from 1% and 4%. Although a few
researchers have investigated this problem, there has been insufficient
study of exploitation based on sexual exchange in the general adolescent
populations. In Canada, only one such study has been published (Lavoie
et al., 2010). In order to better protect youth from this form of sexual
exploitation and to promote their sexual health, the goal of the present
study was to document the prevalence of trading sex for drugs in a large
sample of school-attending youth and to more clearly document the
factors associated with greater and lesser risk of involvement in sexual
exchange. To that end, we examined substance use patterns among grade
7-12 students in a rural area of western Canada and identified
demographic, social, and personality factors that distinguished between
substance-using students who did or did not reported exchanging sex for
drugs.

Methods

Dataset and sample

This study is based on a secondary analysis of data from the East
Kootenay Adolescent Drug Use Survey of 2009, conducted by the East
Kootenay Addiction Services Society. The survey was a biennial census
designed to monitor trends in substance use patterns, related harms, and
attitudes among adolescents in school. The target population included
all grade 7 to 12 students in the East Kootenay region, a large rural
area of southeastern BC. A total of 28 schools participated in the 2009
survey. Parents were provided with an information sheet describing the
survey. Parental notification and student consent were required for
student participation. In February 2009, the anonymous, paper-and-pencil
survey was administered to students in all classrooms. Of 4,126
questionnaires returned, 4,031 were usable in data analysis,
representing 77% of registered students in the East Kootenay area
(Nicholson, 2009).

Our sample included only students who: (a) had ever used alcohol,
marijuana, or other illicit drugs (e.g., mushrooms, inhalants, cocaine);
and (b) provided valid responses to the question "If you have used
alcohol and/or drugs, have you ever used sexual activities in exchange
for or to pay for alcohol and/ or drugs?" Of the original sample
who reported their gender (N = 3,734), 71% reported ever having use of
one or more substances in their lifetime and less than 1% did not
respond to any questions about lifetime substance use. Ten per cent of
students who had used one or more substances in their lifetime did not
answer the question on exchanging sex. The exclusion of these missing
cases resulted in a final sample of 2,360 consisting of 1,154 boys and
1,206 girls.

Measures

Our outcome variable was whether a participant had ever exchanged
sexual activities for alcohol or drugs. In BC under the Criminal Code of
Canada, the definition of sexual exploitation includes situations in
which children or adolescents under age 19 exchange sex for money or
other goods (e.g., drugs). Hence, in the present study, students who
reported having ever exchanged sex are referred to as
"exploited" with the understanding that this is sexual
exploitation. Students who had never exchanged sex in this context are
referred to as "non-exploited".

The survey asked participants how many times in their lives, and in
the past year, they had used the following substances: alcohol,
marijuana, mushrooms, prescription drugs (for non-medical reasons),
inhalants, LSD, cocaine/crack, ecstasy, crystal meth/speed/amphetamines,
steroids, and heroin. Responses to each question were dichotomized into
use (endorsed options indicating substance use) and no use.
Additionally, students were asked about binge drinking. Weekly binge
drinking was defined here as the consumption of five or more drinks on
one occasion on one or more days a week.

Candidate factors associated with sexual exploitation in the
context of sexual exchange

The putative factors associated with sexual exchange for substances
were selected based on literature review and data availability. The
factors included: substance use patterns in the past year; living
situation; social connectedness; social involvement; and personality
risk for substance abuse.

Substance use patterns in the past year

Three groups of substance use patterns in the past year were
created based on a typical sequence of substance use initiation (e.g.,
White, Jarrett, Valencia, Loeber, & Wei, 2007). These patterns were:
(a) using alcohol only in the past year or not using alcohol, marijuana,
or other drugs in the past year; (b) using marijuana with or without
alcohol (but not using other drugs): and (c) using other drugs with or
without alcohol or marijuana.

Living situation

The participants' living situations were dichotomized into a)
living with family and b) living with friends, on their own, or
homeless/couch surfing.

Social connectedness

Family connectedness, friend connectedness, and school
connectedness were assessed each by one item (e.g., "How close do
you feel you are with your family?"). The three items of social
connectedness were scored on a 4-point scale, ranging from "not at
all" (= 0) to "very" (= 1).

Social involvement

The survey also asked the level of involvement of youth with
sports, clubs (e.g., drama, band, 4-H), and community groups or church.
Each involvement item was assessed by one similar question (e.g.,
"How involved are you in sports?"). The three items of social
involvement were scored on a 4-point scale, ranging from "not at
all" (= 0) to "very" (= 1).

Personality risk for substance abuse

The Substance Use Risk Profile Scale (SURPS) (Conrod, Pihl,
Stewart, & Dongier, 2000; Woicik, Stewart, Pihl, & Conrod, 2009)
was used to assess personality vulnerability to substance abuse. The
SURPS consists of four subscales measuring levels of Anxiety Sensitivity
(5 items), Hopelessness (7 items), Sensation Seeking (6 items), and
Impulsivity (5 items). Responses were rated on a 4-point scale, ranging
from "strongly disagree" to "strongly agree" with a
possible score of 0 to 1. An exploratory factor analysis in our study
supported a four-factor solution. However, an intended Sensation Seeking
item, "I am interested in experiences for its own sake even if it
is illegal" loaded on the Impulsivity factor. This item was thus
moved to the Impuisivity subscale. Cronbach's alphas of the
subscales among boys and girls, respectively were 0.68 and 0.66 for
Anxiety Sensitivity, 0.85 and 0.86 for Hopelessness, 0.60 and 0.60 for
Sensation Seeking, and 0.69 and 0.73 for Impulsivity.

Analysis

We performed cross-tabulation analyses with chi-square tests or
Fisher's Exact Tests to compare sexually exploited youth and
non-exploited youth on the prevalence of substance use in their lifetime
and in the past year. To identify factors that differentiated exploited
youth and non-exploited youth, we conducted logistic regression
analyses. The multivariate regression models included variables that
were significantly associated with exchanging sex in bivariate logistic
regression analyses. All analyses were conducted separately by gender.

Missing response rates for each item or scale were less than 5%.
Respondents with missing values were excluded from each analysis on an
analysis-by-analysis basis.

Results

Sample characteristics

Among youth who have ever used alcohol, marijuana, or other drugs,
2.2% of boys and 3.2% of girls reported that they had ever exchanged sex
for substances. The prevalence did not significantly differ by gender (p
= 0.111). There was no significant difference in the mean age between
sexually exploited youth and their non-exploited peers (Table 1). The
majority of the students were living with their family members,
regardless of their histories of trading sex.

Comparisons in the prevalence of substance use

Table 2 summarizes the prevalence of substance use between those
who had ever traded sex for drugs and those who had not. All exploited
students and almost all non-exploited students had ever had alcohol in
their lifetime. No difference was found in the percentage of past-year
alcohol use for either boys or girls. However, exploited boys and girls
had higher proportions of weekly binge drinking.

Sexually exploited youth were more likely than non-exploited youth
to have ever used marijuana and other illicit drugs in their lifetime
and in the past year (Table 2). For example, 77% of exploited girls
reported past-year marijuana use, compared to 43% of non-exploited
girls. A higher proportion of exploited boys than non-exploited boys had
used one or more drugs other than marijuana in the past year (68% vs.
23%).

All of the sexually exploited students and the overwhelming
majority of the non-exploited students (92% of boys and 95% of girls)
reported that they had used alcohol, marijuana, or other drugs in the
past year. Most common patterns of past-year substance use were drinking
alcohol only (no marijuana or other drug use) for non-exploited youth
(43% of boys and 47% of girls) and using alcohol, marijuana, and one or
more other drugs for exploited youth (52% of boys and 67% of girls).

Factors associated with sexual exchange for boys

Among boys, compared to those who used alcohol only or did not use
alcohol or drugs in the past year, students who used drugs other than
marijuana in the past year were more likely to have ever exchanged sex
for alcohol or drugs (Table 3). Boys who did not live with family (i.e.,
living with friends, on their own, homeless, or couch surfing) were also
more likely to report exchanging sex for alcohol or drugs. Boys with a
higher level of hopelessness and boys with a higher level of impulsivity
were more likely to be sexually exploited. Among the social
connectedness variables, only family connectedness was associated with
lower odds of exchanging sex. There was no significant relationship
between any of the social involvement variables and sexual exchange for
boys.

In the multivariate logistic regression model for boys, past-year
use of drugs other than marijuana and not living with family were
significantly linked to higher odds of exchanging sex. The odds of
trading sex were 105 times greater for boys with the highest level of
impulsivity than for boys with the lowest level of impulsivity. Family
connectedness or hopelessness no longer had a significant independent
relation to exchanging sex for drugs (Table 5).

Factors associated with sexual exchange for girls

As was the case with boys, girls who had used other drugs in the
past year, those who had a higher level of hopelessness or a higher
level of impulsivity were more likely to report a history of exchanging
sex for alcohol or drugs (Table 4). Living situation was not a
significant factor for girls. Girls who felt strongly connected to their
family or reported a higher level of involvement in sports or a higher
level of involvement in clubs had lower odds of exchanging sex for
drugs.

Table 5 presents the results of multivariate logistic regression
analysis for girls. Girls who had used drugs other than marijuana in the
past year were more likely to be sexually exploited. Compared to those
with the lowest level of impulsivity, girls with the highest level of
impulsivity had 25 times the odds of exchanging sex for substances. In
the multivariate analyses for girls, neither family connectedness,
involvement in sports, involvement with clubs, nor hopelessness was
independently associated with the exchange of sex.

Discussion

In a sample of adolescents in rural schools who reported ever using
alcohol or other substances, between 2% and 3% had ever exchanged sex
for alcohol or drugs. This rate is comparable to those reported
previously (Edwards et al., 2006; Lavoie et al., 2010; Pedersen &
Hegna, 2003; Svedin & Priebe, 2007). However, the survey asked about
sexual exchange specifically to obtain alcohol or drugs, not for other
purposes such as money. For this reason, our study sample was restricted
to students who had ever used alcohol, marijuana, or other drugs. The
prevalence of trading sex may have been higher if students had been
asked whether or not they had ever exchanged sexual activities for
money, shelter, food, or other goods. In addition, unlike the earlier
studies, similar proportions of boys and girls reported having ever
traded sex. Our results might not be consistent with gendered beliefs
about sexual exchange, i.e., where more boys engage in risky behaviours,
or more girls are sexually exploited. We should recognize that the issue
of sexual exploitation in the context of sexual exchange is not
gender-specific.

Demographic characteristics of adolescents in this study who
reported the exchange of sex may not match the stereotypical idea of
sexually exploited youth. These youth were in school and most were
living with their family members. Trading sex among youth in school
appears to be much less common than among homeless or street-involved
youth; however, a small proportion of students, even in regular schools
in rural areas, appear to have been involved in sexual exchange that
would be defined as sexual exploitation under BC law. These findings
suggest the need for health education about sexual exploitation in
middle schools and high schools.

Lifetime use of alcohol or alcohol use in the past year did not
differentiate between sexually exploited youth and non-exploited youth,
because the vast majority of the sample reported having done so.
However, exploited boys and girls had higher rates of weekly binge
drinking than their non-exploited peers. Similar results have been
reported in other studies (Edwards et al., 2006; Kaestle, 2012; Svedin
& Priebe, 2007). A Norwegian study identified alcohol-related
problems (e.g., psychosocial problems, black-out reactions, dependence)
as a strong factor associated with sexual exchange (Pedersen &
Hegna, 2003). Alcohol-related problems are predicted by binge drinking
and daily alcohol use (Poulin & Elliott, 2007; Read, Beattie,
Chamberlain, & Merrill, 2008). Given that lifetime alcohol use,
including experimental use, among adolescents is relatively common
(Elgar, Phillips, & Hammond, 2011; Nicholson, 2009; Smith et al.,
2009), regular or heavy alcohol consumption may better differentiate
between exploited students and non-exploited students.

The use of illicit drugs other than marijuana appears to be
strongly associated with exchanging sex for substances. Marijuana was
the most widely used drug, with about 70% of exploited youth and nearly
half of non-exploited youth indicating past-year use. On the other hand,
the exploited group had a much higher proportion of past-year other drug
use than the non-exploited group. This disparity was also found in
different past-year substance use patterns between the two groups. Most
of the exploited youth in this study had used other drugs in addition to
alcohol and marijuana. These poly-substance users may have a higher rate
of substance dependence than those who use alcohol only, and may also be
more desperate to obtain drugs. Illicit drugs other than marijuana are
generally less available than alcohol or marijuana (Johnston,
O'Malley, Bachman, & Schulenberg, 2012); thus, trading sex may
be a means of accessing drugs for adolescents in school.

Hopelessness and impulsivity were two significant personality
factors for the exchange of sex in bivariate models. Hopelessness is
strongly correlated with depressive symptoms (Conrod et al., 2000;
Woicik et al., 2009) and depression has been associated with sexual
exchange (Edwards et al., 2006; Kaestle, 2012; Pedersen & Hegna,
2003). However, when other variables such as substance use were
controlled for, hopelessness or depression was no longer a significant
factor in this study and others (Kaestle; Pedersen & Hegna). This
may be because of the mediating effect of substance use. Individuals
with a higher level of hopelessness (or depression) are assumed to use
substances to reduce depressive symptoms (Woicik et al., 2009). That is,
hopelessness increases the risk of substance abuse for self-medication
of depressive symptoms, which in turn, may lead to using sexual
activities in exchange for alcohol or drugs.

In contrast, impulsivity was still a significant risk factor when
substance use in the past year was taken into account. Impulsivity
measured by the SURPS specifically represents one's lack of ability
to inhibit behaviour in the presence of immediate rewards (Conrod et
al., 2000; Woicik et al., 2009). Highly impulsive people may engage in
behaviours that can cause long-term negative consequences due to their
inability to assess potential risks (Woicik et al.). This inability for
planning risk differentiates impulsive people and sensation seekers
(Woicik et al.). Thus, substance-using adolescents may be involved in
the exchange of sex for immediate rewards such as alcohol or drugs, and
sexual pleasure, rather than for sensation seeking, without thinking
about potential negative consequences.

We did not find significant associations between exchanging sex and
any factors of social connectedness or social involvement after
adjusting for risk factors. Similar findings have been obtained by
studies in the U.S. (Kaestle, 2012) and Quebec City (Lavoie et al.,
2010). However, it may be too soon to draw a conclusion about the lack
of protective factors from social relationships and activities. The
social factors were measured by only one item each in this and the U.S.
studies. These single-item measures may lack sufficient capability to
assess complex or multidimensional constructs. Moreover, among school
connectedness variables in the U.S. study, only one item, feeling happy
at school, was uniquely associated with selling sex for compensation,
whereas others (feeling safe at school, feeling part of school, or
feeling school is fair) were not (Kaestle). Some dimensions of school
connectedness may be protective while others may not. The Quebec study
used a 4-item measure of perceived social support from family, friends,
and others who one trusts. Support from different resources may play a
different role in adolescents' involvement in trading sex. For
example, support from friends may not prevent youth from sexual exchange
when their friends engage in risky behaviours, as implied by earlier
studies (Pedersen & Hegna, 2003; Tyler, 2009). On the other hand,
family and school support is generally associated with positive outcomes
(Parcel, Dufur, & Zito, 2010). Likewise, youth participation in
extracurricular activities may or may not be protective, depending on
characteristics of peers with whom they interact (Farb & Matjasko,
2012). The exploration of factors that reduce the odds of exchanging sex
is still limited. We need further studies using more robust measures.

Strengths and limitations of the study

There were several limitations in this study. First, the findings
were based on self-report data; thus, some students may have
underreported sensitive experiences such as trading sex and substance
use. Compared to other questions, the missing response rate for the
question on trading sex was higher. Some students may have hesitated to
answer or may have been unsure about what was asked (e.g., the
definition of "sexual activities"). Therefore, the estimated
prevalence may be an underestimation of this activity. Second, the
cross-sectional nature of the East Kootenay Adolescent Drug Use Survey
did not allow us to make causal or temporal inferences between trading
sex and various risk and protective factors. Third, the survey asked
about exchanging sex, specifically for substances, not for other types
of consideration, such as money, food, or shelter. In addition, the
survey did not ask with whom a respondent exchanged sex for alcohol or
drugs. Such exchanges may be between peers. In fact, the majority of
exploited students in Quebec City reported that partners were under the
age of 19 (Lavoie et al., 2010). Fourth, coefficient alphas of the SURPS
subscales, except Hopelessness, were below 0.80, a level that is
typically interpreted as good consistency. Lower alpha values (<
0.80) for some subscales were also reported in another study of high
school students in Canada (Woicik et al., 2009). However, such lower
values may be due in part to the small number of items in each subscale.
Fifth, as noted above, social connectedness and social involvement were
measured by a single item each, thereby limiting the ability to assess
levels of complex constructs. Finally, due to secondary analysis of
existing data, for the multivariate models we were limited to the
variables available in the original survey. The East Kootenay Adolescent
Drug Use Survey particularly focuses on adolescent substance use and did
not ask about other risky behaviours or family socioeconomic status,
which might be related to trading sex. Sexual abuse and other
victimization experiences, which have been identified as key risk
factors, were not included in our models because the 2009 survey did not
ask those questions.

A strength of the current study is the use of census data collected
from adolescents in school. In particular, our study added information
on the exchange of sex among Canadian students in a large rural area. A
novel finding of this study is that some personality characteristics may
increase the risk of involvement in sexual exchange. Research studies on
this topic have frequently examined behavioural (e.g., substance use),
contextual (e.g., family environments), or mental health (e.g.,
depression) risk factors; but, to our knowledge, none have included
personality factors.

Conclusions and implications

In this secondary analysis using a census of student substance use,
we found that a minority of substance-using adolescents in rural schools
had ever exchanged sexual activities for alcohol or drugs, which is
considered sexual exploitation. Most of those exploited youth were
living with their family members. Students with a history of sexual
exchange were more likely than their peers with no such history to use
drugs other than marijuana and to have an impulsive personality trait.

Future research needs to explore factors that may decrease the
likelihood of involvement in sexual exchange. In addition to
risk-reduction approaches, strength-focused programs have successfully
reduced substance use and risky sexual behaviours among at-risk
adolescents (e.g., Saewyc & Edinburgh, 2010). We should continue our
efforts to prevent and reduce adolescent substance use and abuse. To
reduce the likelihood that youth will trade sex for alcohol or drugs, it
is particularly important to prevent the use of illicit drugs.
Additionally, prevention efforts need to be monitored and evaluated by
periodic surveys like the East Kootenay Adolescent Drug Use Survey.
Besides substance use prevention interventions, in-school education
about healthy relationships and sexual exploitation could help reduce
the risk of involvement in sexual exchange. Skill-based programs may
also help adolescents who are impulsive to control their impulsivity
that can lead to sexual exploitation. In clinical settings, healthcare
practitioners should assess for sexual exploitation among youth who
disclose substance use.

Acknowledgements: The study was funded, in part, by Interior Health
Authority and by grant #HOA-80059 from the Canadian Institutes for
Health Research (Saewyc, PI).

Saewyc, E.M., MacKay, L.J., Anderson, J., and Drozda, C. (2008).
It's not what you think: Sexually exploited youth in British
Columbia. Vancouver, BC: University of British Columbia School of
Nursing. Available at www.nursing.ubc.ca/PDFs/ItsNotWhatYouThink.pdf

United Nations Office of the High Commissioner for Human Rights.
(1989). Convention on the rights of the child, Article 34. Geneva,
Switzerland. Available at http://www2.ohchr.org/english/law/pdf/crc.pdf

United Nations Office of the High Commissioner for Human Rights.
(2000). Convention on the rights of the child, the optional protocol on
the sale of children, child prostitution and child pornography. Geneva,
Switzerland. Available at
http://www2.ohchr.org/english/law/pdf/crc-sale.pdf

Correspondence concerning this article should be addressed to Yuko
Homma, Ph.D., University of British Columbia School of Nursing,
T210-2211 Westbrook Mall, Vancouver, BC V6T 2B5. E-mail:
yuko.homma@ubc.ca